The Provider Network Quality Assurance Specialist is responsible for monitoring, auditing, and improving the quality, accuracy, and compliance of provider network operations. The role supports provider data integrity, regulatory compliance, provider directory accuracy, and continuous process improvement.
This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office (Morrisville, NC) may be required.
Responsibilities & Duties
Conduct Quality Audits of Provider Network Operations Processes
- Develop and maintain an audit schedule
- Conduct research, analyze data, and make recommendations regarding administrative, organizational, and operational problems
- Maintain audit evidence and records to support internal and external review readiness
Support Provider Directory Accuracy and Provider Data Validation Initiatives
- Perform reviews of Provider Directory accuracy and maintain written documentation of reviews and subsequent follow up that will meet both DHB and NCQA requirements
- Compare published information with source systems
- Coordinate provider outreach or internal research to resolve unverified or conflicting information
- Prioritize corrections that could affect member access, search results, or regulatory compliance
- Perform root cause analysis, track corrective actions and provide results
- Cultivate and encourage efforts to expand cross-team collaboration and partnership
Review Provider Records, Contracts, and Enrollment Documentation
- Perform reviews of provider data in Salesforce, Alliance Claims System (ACS) and enrollment and contracting data to identify any trends and document
- Confirm that contract terms, effective dates, network participation, locations, and reimbursement attributes are accurately recorded
- Compare system entries with applications, contracts, enrollment requests and approved change requests
- Identify missing, expired, inconsistent, duplicate, or incorrectly entered information
- Route discrepancies to the appropriate owner and track corrections through completion
Validate Compliance With DHB, NCQA, State, and Organizational Requirements
- Maintain current audit criteria based on applicable regulatory, accreditation, contractual, and internal policy requirements
- Document compliance gaps, assess risk, and escalate significant findings promptly
- Support regulatory requirements, accreditation reviews, and internal compliance assessments by gathering required data and responding to requests
Perform Root Cause Analysis and Track Corrective Actions
- Analyze errors and recurring themes using appropriate root cause methods
- Partner with accountable teams to define corrective and preventive actions, owners, milestones, and due dates
- Document all analysis
Minimum Requirements
Education & Experience
Required:
Bachelor’s Degree in human services; Sociology, Psychology, Public Health, Statistics, Economics, Business Administration or related social science field from an accredited college/university and at least five (5) years of related experience providing quality assurance/improvement activities.
Experience leading project teams focused on quality improvement projects required. Excel proficiency is required to analyze data and to produce graphs and tables.
Preferred:
Prior experience in Managed Care preferred.
Knowledge, Skills, & Abilities
- Superior communication and writing skills.
- Strong organization and time management skills.
- Advance Knowledge of Microsoft office applications, including Excel.
- Proficiency in MicroStrategy or other statistical or data modeling programs.
- Experience developing quality improvement plans for services to persons with complex needs including physical health, behavioral health, and social determinant of health needs.
- Experience with project management processes.
- Ability to manage multiple projects.
- Ability to work with all stakeholders: members, network providers, families, and government staff in a caring and respectful manner, and with due understanding of and consideration for cultural differences.
- Flexibility and willingness to learn new knowledge and skills.
Salary Range
$69,592 -$88,729/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity
An excellent fringe benefit package accompanies the salary, which includes:
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
